In laparoscopic surgery, safe and secure knotting is a cornerstone of successful outcomes. Traditional extracorporeal and intracorporeal knots each have their strengths, but they also have limitations. To overcome these challenges, Dr. R. K. Mishra developed the Mishra’s Knot, a unique extracorporeal knotting technique that combines strength, simplicity, and reproducibility. This technique has become one of the most popular knotting methods taught at the World Laparoscopy Hospital and adopted by surgeons worldwide.

This lecture demonstrates the step-by-step principles and application of Mishra’s Knot in laparoscopic surgery.

Importance of Knotting in Laparoscopy

Unlike open surgery, where surgeons tie knots directly with their fingers, laparoscopic surgery requires knotting through long instruments in a narrow field with limited tactile feedback. A laparoscopic knot must:

Be easy to tie in a limited space.

Provide secure hemostasis.

Withstand the stresses of tissue handling and healing.

Be reproducible across different procedures and anatomical sites.

Mishra’s Knot addresses these requirements with elegance and efficiency.

Concept of Mishra’s Knot

Mishra’s Knot is a modified extracorporeal slip knot, tied outside the body and then introduced into the peritoneal cavity using a knot pusher. Its design ensures:

Maximum knot security comparable to intracorporeal knots.

Quick execution, saving operative time.

Applicability in a wide variety of procedures including myomectomy, appendectomy, cystectomy, and hemostasis of vascular pedicles.

Step-by-Step Demonstration of Mishra’s Knot

Preparation of Suture Material

A long absorbable or non-absorbable suture (commonly polyglactin or silk) is loaded onto a laparoscopic needle holder.

The length of suture used is approximately 90 cm, allowing sufficient thread for extracorporeal manipulation.

Creation of the Base Loop

A loop is made by passing the free end of the suture over the standing part.

This base loop serves as the foundation of the slip knot.

First Half Hitch

The free end is wrapped twice around the standing part, creating a double half hitch.

This provides friction and stability to the knot.

Additional Hitch Formation

A third throw is added in the opposite direction to lock the knot securely.

This arrangement ensures that the knot does not slip once tightened inside the body.

Loading the Knot on the Knot Pusher

The extracorporeal knot is loaded onto a Mishra’s Knot Pusher, a specialized instrument designed to advance the knot along the suture.

The standing part of the suture is held taut, and the knot pusher is threaded over it.

Insertion into the Abdominal Cavity

Under laparoscopic visualization, the knot pusher is advanced through a 10 mm port into the abdominal cavity.

The knot slides smoothly along the suture without loosening.

Securing the Knot at the Target Site

Once the knot reaches the tissue or pedicle requiring ligation, steady pressure is applied using the knot pusher.

The knot tightens securely, providing firm hemostasis.

Reinforcement

Additional half hitches may be delivered intracorporeally or extracorporeally to reinforce the knot if needed.

Applications of Mishra’s Knot

Mishra’s Knot is versatile and can be used in multiple laparoscopic procedures:

Laparoscopic Myomectomy: Securing the myometrial defect after enucleation of fibroids.

Laparoscopic Appendectomy: Ligation of the appendicular base and mesoappendix.

Cholecystectomy: Controlling the cystic duct or artery when clips are not suitable.

Ovarian Cystectomy: Achieving hemostasis of ovarian pedicles.

Hernia Repair: Securing mesh or peritoneal flaps.

It is particularly valuable in situations where staplers or advanced energy devices are not available, making it a cost-effective option.

Advantages of Mishra’s Knot

High Knot Security: Equal or superior to traditional Roeder’s knot or Duncan’s loop.

Ease of Learning: Simplified technique allows surgeons, even beginners, to master it quickly.

Versatility: Applicable across multiple laparoscopic procedures.

Cost-Effective: Reduces reliance on expensive staplers or clip applicators.

Reproducibility: Can be tied consistently with minimal variation.

Limitations

Requires a knot pusher and familiarity with extracorporeal knotting.

Not suitable for very deep pelvic sites with restricted instrument mobility.

Proper technique must be maintained to avoid slippage.

Post-Demonstration Notes

In Dr. R. K. Mishra’s demonstration, emphasis is placed on repetition and practice. Surgeons are encouraged to practice Mishra’s Knot on dry lab models before applying it clinically. Proper hand-eye coordination, smooth suture handling, and controlled advancement of the knot pusher are essential for flawless execution.

Conclusion

The Mishra’s Knot represents an important innovation in laparoscopic surgery, bridging the gap between intracorporeal and extracorporeal knotting. Its combination of security, simplicity, and versatility makes it one of the most widely taught techniques in advanced laparoscopic training. As demonstrated by Dr. R. K. Mishra, with consistent practice, surgeons can perform Mishra’s Knot quickly and confidently, ensuring safe and effective outcomes across a wide spectrum of laparoscopic procedures.